Search results for: clinical simulation

Authors: Jeounghee Kim

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Objective: To describe the incidence of complication, according to the stage of Traumatic Spinal Cord Injury (TSCI) which was treated at Asan Medical Center (AMC), Korea. Hereafter, it should be developed in nursing management protocol of traumatic SCI. Methods. Retrospectively reviewed hospital records about the patients who were admitted AMC Patients with traumatic spinal cord injury until January 2005 and December 2016 were analyzed (n=97). AMC is a single institution of 2,700 beds where patients with trauma and severe trauma can be treated. Patients who were admitted to the emergency room due to spinal cord injury and who underwent intensive care unit, general ward, and rehabilitation ward. To identify long-term complications, we excluded patients who were operated on to other hospitals after surgery. Complications such as respiratory(pneumonia, atelectasis, pulmonary embolism, and others), cardiovascular (hypotension), urinary (autonomic dysreflexia, urinary tract infection (UTI), neurogenic bladder, and others), and skin systems (pressure ulcers) from the time of admission were examined through medical records and images. Results: SCI was graded according to ASIA scale. The initial grade was checked at admission. (grade A 55(56.7%), grade B 14(14.4)%, grade C 11(11.3%), grade D 15(15.5%), and grade E 2(2.1%). The grade was rechecked when the patient was discharged after treatment. (grade A 43(44.3%), grade B 15(15.5%), grade C 12(12.4%), grade D 21(21.6%), and grade E 6(6.2%). The most common complication after SCI was UTI 24cases (mean 36.5day), sore 24cases (40.5day), and Pneumonia which was 23 cases after 10days averagely. The other complications after SCI were neuropathic pain 19 cases, surgical site infection 4 cases. 53.6% of patient who had SCI were educated about intermittent catheterization at discharge from hospital. The mean hospital stay of all SCI patients was 61days. Conclusion: The Complications after traumatic SCI were developed at various stages from acute phase to chronic phase. Nurses need to understand fully the time-course of complication in traumatic SCI to provide evidence-based practice.

Keywords: spinal cord injury, complication, nursing, rehabilitation

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Authors: Y. L. Hor, H. S. Chu, V. P. Bui

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Composite material is widely used to replace conventional material, especially in the aerospace industry to reduce the weight of the devices. It is formed by combining reinforced materials together via adhesive bonding to produce a bulk material with alternated macroscopic properties. In bulk composites, degradation may occur in microscopic scale, which is in each individual reinforced fiber layer or especially in its matrix layer such as delamination, inclusion, disbond, void, cracks, and porosity. In this paper, we focus on the detection of defect in matrix layer which the adhesion between the composite plies is in contact but coupled through a weak bond. In fact, the adhesive defects are tested through various nondestructive methods. Among them, pulsed phase thermography (PPT) has shown some advantages providing improved sensitivity, large-area coverage, and high-speed testing. The aim of this work is to develop an efficient numerical model to study the application of PPT to the nondestructive inspection of weak bonding in composite material. The resulting thermal evolution field is comprised of internal reflections between the interfaces of defects and the specimen, and the important key-features of the defects presented in the material can be obtained from the investigation of the thermal evolution of the field distribution. Computational simulation of such inspections has allowed the improvement of the techniques to apply in various inspections, such as materials with high thermal conductivity and more complex structures.

Keywords: pulsed phase thermography, weak bond, composite, CFRP, computational modelling, optimization

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Authors: Naheem Olakunle Adesina

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The memristor is considered as one of the promising candidates for mamoelectronic engineering and applications. Owing to its high compatibility with CMOS, nanoscale size, and low power consumption, memristor has been employed in the design of commonly used circuits such as phase-locked loop (PLL). In this paper, we designed a memristor-based loop filter (LF) together with other components of PLL. Following this, we evaluated the noise-rejection feature of loop filter by comparing the noise levels of input and output signals of the filter. Our SPICE simulation results showed that memristor behaves like a linear resistor at high frequencies. The result also showed that loop filter blocks the high-frequency components from phase frequency detector so as to provide a stable control voltage to the voltage controlled oscillator (VCO). In addition, we examined the effects of temperature on the performance of the designed phase locked loop circuit. A critical temperature, where there is frequency drift of VCO as a result of variations in control voltage, is identified. In conclusion, the memristor is a suitable choice for nanoelectronic systems owing to a small area, low power consumption, dense nature, high switching speed, and endurance. The proposed memristor-based loop filter, together with other components of the phase locked loop, can be designed using memristive emulator and EDA tools in current CMOS technology and simulated.

Keywords: Fast Fourier Transform, hysteresis curve, loop filter, memristor, noise, phase locked loop, voltage controlled oscillator

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Authors: Akhigbe Mark, Abang Roger, Mwoltu Nanaribet, Edet Blessing

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Introduction.: The introduction of pre- exposure prophylaxis (PrEP) as a biomedical prevention method for HIV/AIDS has been around for more than a decade since the first confirmed evidence of its effectiveness when used daily as an oral pill. It is now a very valuable addition for people who are at higher risk of contracting HIV. Although globalacceptanceof PrEP hasincreased, PrEP is still highly concentrated in a small number of countries and within a small sub-population, with Kenya and South Africa accounting for only 19% of people who have received PrEP in Africa region, there is still a significant regionGap in PrEP availability and use, with only 28% of the target of 3 million in low-and middle countries currently using PrEP. Description: The purpose of this study is to find out if serum creatinine could be used as an incentive to improve PrEP uptake among Key population.Numerous approaches to increasing the uptake ofPrEP as a prevention mechanism for HIV in KPs has beenemployed, and one of them is serum creatinine. This approach is a biomarker of renal function, which was used in study as an incentive to increase PrEP uptake among key population groups (female sex workers, men who have sex with men, persons who inject drugs, transgender) in 3 states from South-South Nigeria. Whole blood samples are collected from clients, analysis of the samples is done using the clinical chemistry analyzer before they are initiated onto PrEP. Lessons learned and Recommendations: Secondary data was extracted from 3 states of HALG Implementing facilities in Southern part of Nigeria, PrEP uptake before and afterthe introduction of serum creatinine between March 2020 and August 2020 among key populationsin Nigeria. A total of 5664 patients were initiated on PrEP before, and after the introduction of serum creatinine, the PrEP uptake rate before (March 2020 to May 2020) introduction of serum creatinine accounted for only 5% of the total onset, and after (June 2020 to August 2020) introduction of serum creatinine, the uptake rate accounted for 95% of the total onset. These finding shows that increased uptake of PrEP before/after serum creatineindicates that serum creatine may be an effective stimulus for promoting PrEP in key populations.

Keywords: serum creatinine, incentives, PrEP, key populations, Nigeria

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Authors: R. Bužgová, R. Kozáková, M. Škutová, M. Bar, P. Ressner, P. Bártová

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Introduction: Currently, there has been an increasing concern about the provision of palliative care in non-oncological patients in both professional literature and clinical practice. However, there is not much scientific information on how to provide neurological and palliative care together. The main objective of the project is to create and to verify a concept of neuro-palliative and rehabilitative care for patients with selected neurological diseases in an advanced stage of the disease and also to evaluate bio-psychosocial and spiritual needs of these patients and their caregivers related to the quality of life using created standardized tools. Methodology: Triangulation of research methods (qualitative and quantitative) will be used. A concept of care and assessment tools will be developed by analyzing interviews and focus groups. Qualitative data will be analyzed using grounded theory. The concept of care will be tested in the context of the intervention study. Using quantitative analysis, we will assess the effect of an intervention provided on the saturation of needs, quality of life, and quality of care. A research sample will be made up of the patients with selected neurological diseases (Parkinson´s syndrome, motor neuron disease, multiple sclerosis, Huntington’s disease), together with patients´ family members. Based on the results, educational materials and a certified course for health care professionals will be created. Findings: Based on qualitative data analysis, we will propose the concept of integrated care model combining neurological, rehabilitative and specialist palliative care for patients with selected neurological diseases in different settings of care and services. Patients´ needs related to quality of life will be described by newly created and validated measuring tools before the start of intervention (application of neuro-palliative and palliative approach) and then in the time interval. Conclusion: Based on the results, educational materials and a certified course for doctors and health care professionals will be created.

Keywords: multidisciplinary approach, neuropalliative care, research, quality of life

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Authors: D. Sun, T. F. Lu, A. Zander, M. Trinkle

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This paper investigates the potential use of airborne ultrasonic phased arrays for imaging in outdoor environments as a means of overcoming the limitations experienced by kinect sensors, which may fail to work in the outdoor environments due to the oversaturation of the infrared photo diodes. Ultrasonic phased arrays have been well studied for static media, yet there appears to be no comparable examination in the literature of the impact of a flowing medium on the focusing behaviour of near field focused ultrasonic arrays. This paper presents a method for predicting the sound pressure fields produced by a single ultrasound element or an ultrasonic phased array influenced by airflows. The approach can be used to determine the actual focal point location of an array exposed in a known flow field. From the presented simulation results based upon this model, it can be concluded that uniform flows in the direction orthogonal to the acoustic propagation have a noticeable influence on the sound pressure field, which is reflected in the twisting of the steering angle of the array. Uniform flows in the same direction as the acoustic propagation have negligible influence on the array. For an array impacted by a turbulent flow, determining the location of the focused sound field becomes difficult due to the irregularity and continuously changing direction and the speed of the turbulent flow. In some circumstances, ultrasonic phased arrays impacted by turbulent flows may not be capable of producing a focused sound field.

Keywords: airborne, airflow, focused sound field, ultrasonic phased array

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Authors: Anne N. Heirman, Lisette van der Molen, Richard Dirven, Gyorgi B. Halmos, Michiel W.M. van den Brekel

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Background: Due to the rising incidence of oropharyngeal squamous cell cancer (OPSCC), many patients are challenged with choosing between transoral(robotic) surgery and radiotherapy, with equal survival and oncological outcomes. Also, functional outcomes are of little difference over the years. With this study, the wants and needs of patients and caregivers are identified to develop a comprehensible patient decision aid (PDA). Methods: The development of this PDA is based on the International Patient Decision Aid Standards criteria. In phase 1, relevant literature was reviewed and compared to current counseling papers. We interviewed ten post-treatment patients and ten doctors from four head and neck centers in the Netherlands, which were transcribed verbatim and analyzed. With these results, the first draft of the PDA was developed. Phase 2 beholds testing the first draft for comprehensibility and usability. Phase 3 beholds testing for feasibility. After this phase, the final version of the PDA was developed. Results: All doctors and patients agreed a PDA was needed. Phase 1 showed that 50% of patients felt well-informed after standard care and 35% missed information about treatment possibilities. Side effects and functional outcomes were rated as the most important for decision-making. With this information, the first version was developed. Doctors and patients stated (phase 2) that they were satisfied with the comprehensibility and usability, but there was too much text. The PDA underwent text reduction revisions and got more graphics. After revisions, all doctors found the PDA feasible and would contribute to regular counseling. Patients were satisfied with the results and wished they would have seen it before their treatment. Conclusion: Decision-making for OPSCC should focus on differences in side-effects and functional outcomes. Patients and doctors found the PDA to be of great value. Future research will explore the benefits of the PDA in clinical practice.

Keywords: head-and-neck oncology, oropharyngeal cancer, patient decision aid, development, shared decision making

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Authors: Bliss Singhal

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Epilepsy is a prevalent neurological disorder affecting approximately 50 million individuals worldwide and 1.2 million Americans. There exist millions of pediatric patients with intractable epilepsy, a condition in which seizures fail to come under control. The occurrence of seizures can result in physical injury, disorientation, unconsciousness, and additional symptoms that could impede children's ability to participate in everyday tasks. Predicting seizures can help parents and healthcare providers take precautions, prevent risky situations, and mentally prepare children to minimize anxiety and nervousness associated with the uncertainty of a seizure. This research proposes a comprehensive framework to predict seizures in pediatric patients by evaluating machine learning algorithms on unimodal neuroimaging data consisting of electroencephalogram signals. The bandpass filtering and independent component analysis proved to be effective in reducing the noise and artifacts from the dataset. Various machine learning algorithms’ performance is evaluated on important metrics such as accuracy, precision, specificity, sensitivity, F1 score and MCC. The results show that the deep learning algorithms are more successful in predicting seizures than logistic Regression, and k nearest neighbors. The recurrent neural network (RNN) gave the highest precision and F1 Score, long short-term memory (LSTM) outperformed RNN in accuracy and convolutional neural network (CNN) resulted in the highest Specificity. This research has significant implications for healthcare providers in proactively managing seizure occurrence in pediatric patients, potentially transforming clinical practices, and improving pediatric care.

Keywords: intractable epilepsy, seizure, deep learning, prediction, electroencephalogram channels

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Authors: Mohammed M. Mahdy Tawfeek

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Objective: The aim of this work is to compare the outcome of photoactivated chromophore for keratitis-cross linking (PACK-CXL) window absorption (WA) alone with combined PACK-CXL WA and standard anti-microbial therapy (SAT) for the treatment of infectious keratitis. Patients and Methods: This is a randomized prospective comparative clinical trial. Thirty eyes with clinically suspected infectious keratitis were randomly assigned into two equal groups of 15 eyes each: Group (A) was treated by PACK-CXL WA alone and group (B) was treated by PACK-CXL WA combined with SAT. Identification of organisms was made by lab study before treatment. Corneal healing was evaluated by corneal examination and anterior segment OCT (AS-OCT). Written informed consent was obtained from all participants and the study was approved by the research ethics committee of the Faculty of Medicine, Zagazig University. The work has been carried out in accordance with The Code of Ethics of the World Medical Association (Declaration of Helsinki) for studies involving humans. Results: Complete healing and resolution (Successful treatment) were observed in 10 eyes (66.7%) of a group (A) and 14 eyes (93.3%) of group (B) and failure was observed in 5 eyes (33.3%) of a group (A) and one eye (6.67%) of group (B). They were statistically significant (P =0.042 and 0.003) in a comparison between both groups regarding success and failure of treatment, respectively. Complete corneal healing was reported in the third month postoperatively in 10 eyes (66.7%) of group (A) and 14 eyes (93.3%) of group (B). Complications were absent in 12 patients (80%) in group (A) and 14 patients (93.3%) of group (B); however, perforation and impending perforation were found in 3 patients of group (A) and only one patient of group (B). Conclusion: PACK-CXL is a promising, non-invasive treatment option for infectious keratitis, especially when performed with the window absorption (WA) technique, either alone or combined with SAT. It has a synergistic effect with a standard antimicrobial treatment that gives good outcome results in the treatment of infectious keratitis. Also, it avoids the antibiotics resistance that has become rapidly spreading worldwide.

Keywords: corneal cross linking, infectious keratitis, PACK-CXL, window absorption

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Authors: F. Berahmandpour, K. Bagheri

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Introduction: Spirulina is nutritious blue - green algae which are used as supplement or a preservative in many foods. The studies about the algae argue that the Spirulina can improve immune system, increase fat utilization, reduce oxidative stress and promote endurance at high-intensity exercise. The purpose of study is to assess the effects of Spirulina supplement on healthy weight control. Method: the study is a cross-sectional study which had 30 participants. The participants were men and women who referred to the nutrition and diet therapy clinic (in west of Tehran / Iran) for control weight. The sampling was a purposeful sampling. The participants were divided into three groups, and they were surveyed for 4 weeks. In the first group, 10 participants were used Spirulia supplement (dose: 500mg of Spiruvit Supplement as tablet / 3 times per day) without any special diet. The second group was 10 participants who received Spirulia supplement (dose 500mg of Spiruvit Supplement as tablet / 3 times per day) with a weight loss exercise program and without any special diet. The third group was 10 participants who used Spirulia supplement (dose 500mg of Spiruvit Supplement as tablet / 3 times per day) with an optimum weight loss diet. Results and Discussion: The results show that there were not any significant loss weights in first group. In while, the participants of second group argued that the Spirulina supplement had positive effects on their mud and physical body; however the clinical results showed that the loss weight had fixed tilt in this group. The significant results of study were related to the third group, because the participations could continuous loss weight during 4 weeks. However, the optimum weight loss diets were effective effects on weight loss in this group, but the researchers found that Spirulina supplement could improve loss weight with set of hormonal system (especially in women with menopause). Conclusion: The study is concluded that the Spirulina as a supplement (Spiruvit Supplement) can be an effective effect on healthy weight control, if it is used with a nutritious healthy weight loss diet. In fact, the effect of Spirulina can be related to powerful antioxidant effects and improvable hormonal system in the body.

Keywords: diet, healthy weight control, spirulina, spiruvit supplement

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Authors: Eva Kirzner

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Based on outcome studies published over the past two decades, in 2018, the ACC/AHA published new guidelines for the management of hypercholesterolemia that incorporate the use of coronary artery calcium (CAC) scanning as a decision tool for ascertaining which patients may benefit from statin therapy. This use is based on the recognition that the absence of calcium on CAC scanning (i.e., a CAC score of zero) usually signifies the absence of significant atherosclerotic deposits in the coronary arteries. Specifically, in patients with a high risk for atherosclerotic cardiovascular disease (ASCVD), initiation of statin therapy is generally recommended to decrease ASCVD risk. However, among patients with intermediate ASCVD risk, the need for statin therapy is less certain. However, there is a need for new outcome studies that provide evidence that the management of hypercholesterolemia based on these new ACC/AHA recommendations is safe for patients. Based on a Pub-Med and Google Scholar literature search, four relevant population-based or patient-based cohort studies that studied the relationship between CAC scanning, risk assessment or mortality, and statin therapy that were published between 2017 and 2021 were identified (see references). In each of these studies, patients were assessed for their baseline risk for atherosclerotic cardiovascular disease (ASCVD) using the Pooled Cohorts Equation (PCE), an ACC/AHA calculator for determining patient risk based on assessment of patient age, gender, ethnicity, and coronary artery disease risk factors. The combined findings of these four studies provided concordant evidence that a zero CAC score defines patients who remain at low clinical risk despite the non-use of statin therapy. Thus, these new studies confirm the use of CAC scanning as a safe tool for reducing the potential overuse of statin therapy among patients with zero CAC scores. Incorporating these new data suggest the following best practice: (1) ascertain ASCVD risk according to the PCE in all patients; (2) following an initial attempt trial to lower ASCVD risk with optimal diet among patients with elevated ASCVD risk, initiate statin therapy for patients who have a high ASCVD risk score; (3) if the ASCVD score is intermediate, refer patients for CAC scanning; and (4) and if the CAC score is zero among the intermediate risk ASCVD patients, statin therapy can be safely withheld despite the presence of an elevated serum cholesterol level.

Keywords: cholesterol, cardiovascular disease, statin therapy, coronary calcium

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Authors: Keng H. Kong, Louis C. Tan, Wing L. Aw, Kay Y. Tay

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Background: Fatigue is a common problem in patients with Parkinson's disease, with reported prevalence of up to 70%. Fatigue can be disabling and has adverse effects on patients' quality of life. There is currently no satisfactory treatment of fatigue. Acupuncture is effective in the treatment of fatigue, especially that related to cancer. Its role in Parkinson's disease-related fatigue is uncertain. Aims: To evaluate the clinical efficacy of acupuncture treatment in Parkinson's disease-related fatigue. Hypothesis: We hypothesize that acupuncture is effective in alleviating Parkinson's disease-related fatigue. Design: A single center, randomized, controlled study with two parallel arms. Participants: Forty participants with idiopathic Parkinson's disease will be enrolled. Interventions: Participants will be randomized to receive verum (real) acupuncture or placebo acupuncture. The retractable non-invasive sham needle will be used in the placebo group. The intervention will be administered twice a week for five weeks. Main outcome measures: The primary outcome will be the change in general fatigue score of the multidimensional fatigue inventory at week 5. Secondary outcome measures include other subscales of the multidimensional fatigue inventory, movement disorders society-unified Parkinson's disease rating scale, Parkinson's disease questionnaire-39 and geriatric depression scale. All outcome measures will be assessed at baseline (week 0), completion of intervention (week 5) and 4 weeks after completion of intervention (week 9). Results: To date, 23 participants have been recruited and nine have completed the study. The mean age is 63.5±14.2 years, mean duration of Parkinson’s disease is 6.4±1.8 years and mean MDS-UPDRS score is 8.3±2.8. The mean general fatigue score of the multidimensional fatigue inventory is 13.5±4.6. No significant adverse event related to acupuncture is noted. Potential significance: If the results are as expected, this study will provide preliminary scientific evidence for the efficacy of acupuncture in Parkinson's Disease-related fatigue, and opens the door for a larger multicentre trial to be performed. In the longer term, it may lead to the integration of acupuncture in the care of patients with Parkinson's disease.

Keywords: acupuncture, fatigue, Parkinson's disease, trial

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Authors: AliAkbar Hafezi, Jalal Taherian, Jamshid Abedi, Mahsa Elahi, Behnam Kadkhodaei

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Background: Soft tissue sarcomas (STS) are generally treated with a combination of limb preservation surgery and radiation therapy. Today, preoperative radiation therapy is considered for accurate treatment volume and smaller field size. Therefore, this study was performed to compare preoperative with postoperative radiation therapy in patients with extremity STS. Methods: In this non-randomized clinical trial, patients with localized extremity STS referred to the orthopedic clinics in Iran from 2021 to 2023 were studied. Patients were randomly divided into two groups: preoperative and postoperative radiation therapy. The two groups of patients were compared in terms of acute (wound dehiscence and infection) and late (limb edema, subcutaneous fibrosis, and joint stiffness) complications and their severity, as well as local recurrence and other one-year outcomes. Results: A total of 80 patients with localized extremity STS were evaluated in two treatment groups. The groups were matched in terms of age, sex, history of diabetes mellitus, hypertension, smoking, involved side, involved extremity, lesion location, and tumor histopathology. The acute complications of treatment in the two groups of patients did not differ significantly (P > 0.05). Of the late complications, only joint stiffness between the two groups had significant statistical differences (P < 0.001). The severity of all three late complications in the postoperative radiation therapy group was significantly higher (P < 0.05). There was no significant difference between the two groups in terms of the rate of local recurrence of other one-year outcomes (P > 0.05). Conclusion: This study showed that in patients with localized extremity STS, the two therapeutic approaches of adjuvant and neoadjuvant radiation therapy did not differ significantly in terms of local recurrence and distant metastasis during the one-year follow-up period and due to fewer late complications in preoperative radiotherapy group, this treatment approach can be a better choice than postoperative radiation therapy.

Keywords: soft tissue sarcoma, extremity, preoperative radiation therapy, postoperative radiation therapy

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Authors: Leticia Cervantes, Edith Garcia, Oscar Castillo

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At today, there are several control problems where the main objective is to obtain the best control in the study to decrease the error in the application. Many techniques can use to control these problems such as Neural Networks, PID control, Fuzzy Logic, Optimization techniques and many more. In this case, fuzzy logic with fuzzy system and an optimization technique are used to control the case of study. In this case, Ant Lion Optimization is used to optimize a fuzzy system to control the velocity of a simple treadmill. The main objective is to achieve the control of the velocity in the control problem using the ALO optimization. First, a simple fuzzy system was used to control the velocity of the treadmill it has two inputs (error and error change) and one output (desired speed), then results were obtained but to decrease the error the ALO optimization was developed to optimize the fuzzy system of the treadmill. Having the optimization, the simulation was performed, and results can prove that using the ALO optimization the control of the velocity was better than a conventional fuzzy system. This paper describes some basic concepts to help to understand the idea in this work, the methodology of the investigation (control problem, fuzzy system design, optimization), the results are presented and the optimization is used for the fuzzy system. A comparison between the simple fuzzy system and the optimized fuzzy systems are presented where it can be proving the optimization improved the control with good results the major findings of the study is that ALO optimization is a good alternative to improve the control because it helped to decrease the error in control applications even using any control technique to optimized, As a final statement is important to mentioned that the selected methodology was good because the control of the treadmill was improve using the optimization technique.

Keywords: ant lion optimization, control problem, fuzzy control, fuzzy system

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Authors: Laïd Boukraâ

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Complementary and Alternative Medicine is an inclusive term that describes treatments, therapies, and modalities that are not accepted as components of mainstream education or practice, but that are performed on patients by some practitioners. While these treatments and therapies often form part of post-graduate education, study and writing, they are generally viewed as alternatives or complementary to more universally accepted treatments. Ancient civilizations used bee products and medicinal plants, but modern civilization and ‘education’ have seriously lessened our natural instinctive ability and capability. Despite the fact that the modern Western establishment appears to like to relegate apitherapy and aromatherapy to the status of 'folklore' or 'old wives' tales', they contain a vast spread of pharmacologically-active ingredients and each one has its own unique combination and properties. They are classified in modern herbal medicine according to their spheres of action. Bee products and medicinal plants are well-known natural product for their healing properties and their increasing popularity recently as they are widely used in wound healing. Honey not only has antibacterial properties which can help as an antibacterial agent but also has chemical properties which may further help in the wound healing process. A formulation with honey as its main component was produced into a honey gel. This new formulation has enhanced texture and is more user friendly for usage as well. This new formulation would be better than other formulas as it is hundred percent consisting of natural products and has been made into a better formulation. In vitro assay, animal model study and clinical trials have shown the effectiveness of LEADERMAX for the treatment of diabetic foot, burns, leg ulcer and bed sores. This one hundred percent natural product could be the best alternative to conventional products for wound and burn management. The advantages of the formulation are: 100% natural, affordable, easy to use, strong power of absorption, dry surface on the wound making a film, will not stick to the wound bed; helps relieve wound pain, inflammation, edema and bruising while improving comfort.

Keywords: bed sore bee products, burns, diabetic foot, medicinal plants, leg ulcer, wounds

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Authors: Supriya Patibanda, Xiaopeng Gong, Krishna N. Jonnalagadda, Ralph Abrahams

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Yttria stabilized zirconia (YSZ) is used as a top coat in thermal barrier coatings in high-temperature turbine/jet engine applications. The mechanical behaviour of YSZ depends on the microstructural features like crack density and porosity, which are a result of coating method. However, experimentally ascertaining their individual effect is difficult due to the inherent challenges involved like material synthesis and handling. The current work deals with the development of a phenomenological model to replicate the tensile behavior of air plasma sprayed YSZ obtained from experiments. Initially, uniaxial tensile experiments were performed on freestanding YSZ coatings of ~300 µm thick for different crack densities and porosities. The coatings exhibited a nonlinear behavior and also a huge variation in strength values. With the obtained experimental tensile curve as a base and crack density and porosity as prime variables, a phenomenological model was developed using ABAQUS interface with new user material defined employing VUMAT sub routine. The relation between the tensile stress and the crack density was empirically established. Further, a parametric study was carried out to investigate the effect of the individual features on the non-linearity in these coatings. This work enables to generate new coating designs by varying the key parameters and predicting the mechanical properties with the help of a simulation, thereby minimizing experiments.

Keywords: crack density, finite element method, plasma sprayed coatings, VUMAT

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Authors: Tobias Schramm, Günther Prokop

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Degraded vehicle shock absorbers represent a risk for road safety. The exact effect of degraded vehicle dampers on road safety is still the subject of research. This work is intended to contribute to estimating the effect of degraded twin-tube dampers of passenger cars on road safety. An axle model was built using a damper model to simulate different degradation levels. To parameterize the model, a realistic parameter space was estimated based on test rig measurements and database analyses, which is intended to represent the vehicle field in Germany. Within the parameter space, simulations of the axle model were carried out, which calculated the transmittable lateral forces of the various axle configurations as a function of vehicle speed, road surface, damper conditions and axle parameters. A degraded damper has the greatest effect on the transmittable lateral forces at high speeds and in poor road conditions. If a vehicle is traveling at a speed of 100 kph on a Class D road, a degraded damper reduces the transmissible lateral forces of an axle by 20 % on average. For individual parameter configurations, this value can rise to 50 %. The axle parameters that most influence the effect of a degraded damper are the vertical stiffness of the tire, the unsprung mass and the stabilizer stiffness of the axle.

Keywords: vehicle dynamics, vehicle simulation, vehicle component degradation, shock absorber model, shock absorber degradation

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Authors: Atefeh Abedini, Pegah Soltani, Arda Kiani

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Background: Sarcoidosis and Tuberculosis are both considered granulomatous chronic diseases with some similar pulmonary and extra-pulmonary manifestations. It is hypothesized that given these morphological similarities, the genome of mycobacterium could have an impact on the development of Sarcoidosis. Identifying the potential correlation of these diseases may assist in the management of sarcoidosis. Herein, we aimed to inspect the lymph node biopsy of sarcoidosis patients for the existence of the HSP-65 mycobacterium DNA sequence. Methods: This cross-sectional survey was conducted on 1188 Sarcoidosis patients without active/latent tuberculosis infection who were diagnosed in Masih Daneshvari Hospital in Tehran, Iran, from January 2020 to January 2022. Trans-bronchial needle aspiration (TBNA) was performed due to bilateral hilar lymphadenopathy to take a specimen. Results: The under-evaluated patients were mainly women (N=815 (68.6%)), none-smoker (N=1016 (85.5%)), and middle-aged (50.1 (SD=4.22)) with average angiotensin-converting enzyme (ACE) index of 75.6 (SD=6.42). Dyslipidemias (n=314 (26.4%), Hypertension (n=295 (24.8%)), Diabetes mellitus (n=131 (11.0%)), and chronic heart diseases (n=97 (8.2%)) had the highest prevalence between comorbidities. Skin lesions (n= 655 (55.1%)), ophthalmic (n=341 (28.7%)), and cardiac involvement (n=229 (19.3%)) were obtained as the most common extra-pulmonary characteristics of the patients. Amongst 1188 enrolled patients who were not afflicted with Mycobacterium tuberculosis based on smear/culture essay, clinical symptoms, and Chest x-ray screening, 121 (10.2%) cases had detectable amplified DNA for Mycobacterium Tuberculosis extracted from mediastinal lung lymph nodes. Conclusion: In this survey, the mycobacterium genome was detected in almost 1 per 10 case biopsies of sarcoidosis. The remarkable number of cases (n=1188) evaluated in this study was the strength of this study which supported the hypothesis regarding sarcoidosis and mycobacterium genome correlation. Further investigation, such as case-control surveys, is required to better clarify this association.

Keywords: mycobacterium tuberculosis, sarcoidosis, genome, DNA, trans-bronchial needle aspiration

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Authors: Miriam Colleran, Barbara Sheehy-Skeffington

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Background: To explore if there are unique features in the palliative care needs of patients with intellectual disability that may impact on planning for resource and service provision for them. Aim: The purpose of this practice review is to assess the indications for, numbers of and outcomes of care for adults with intellectual disabilities referred to a specialist palliative care service over a twoyear period. Service utilization aspects considered included the frequency of home visits by a specialist palliative care doctor or clinical nurse specialist and the number of hospice admissions that occurred for the patients. Method: A retrospective review was carried out of persons 18 years and older with intellectual disabilities referred to a specialist palliative care service over a 5-year period from 30.11.3018 to 29.11.2023. A manual review was carried out of the register using key terms, namely, known residential care and community dwelling places of service providers for persons with intellectual disabilities in the area and registered diagnoses in addition to the patients known to the clinicians who had intellectual disabilities. Results: 25 referrals were made to the specialist palliative care service of 23 persons with intellectual disabilities during that time. However, this may be an underestimate. 15 women and 8 men were referred with an age range of 19 to 86 years of age. The majority had a diagnosis of Down’s syndrome or Trisomy 21. 5 patients referred did not have home visits from the specialist palliative care team. A range of 2 to 48 phone calls per person occurred by the specialist palliative care team regarding this cohort of patients. The outcomes for the patients included discharge and death. The majority of patients that died, did so in the community. One person however died in hospital. Another person died in a hospice out of area. Conclusion: Providing specialist palliative care for adults with intellectual disabilities is an important element of palliative care. The dominance of the community as the place of death for these patients and the limited number of patients dying in either hospice or hospital are noteworthy. Further research is necessary and education to inform, support, and empower specialist palliative care professionals in optimizing palliative and end-of-life care for persons with intellectual disabilities and to inform service development and provision.

Keywords: about intellectual disability, palliative care

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Authors: P. Booma Devi, Dilip A. Shah

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This paper seeks the potentials of studying aerodynamic characteristics of inward cavities called dimples, as an alternative to the classical vortex generators. Increasing stalling angle is a greater challenge in wing design. But our examination is primarily focused on increasing lift. In this paper, enhancement of lift is mainly done by introduction of dimple or cavity in a wing. In general, aircraft performance can be enhanced by increasing aerodynamic efficiency that is lift to drag ratio of an aircraft wing. Efficiency improvement can be achieved by improving the maximum lift co-efficient or by reducing the drag co-efficient. At the time of landing aircraft, high angle of attack may lead to stalling of aircraft. To avoid this kind of situation, increase in the stalling angle is warranted. Hence, improved stalling characteristic is the best way to ease landing complexity. Computational analysis is done for the wing segment made of NACA 0012. Simulation is carried out for 30 m/s free stream velocity over plain airfoil and different types of cavities. The wing is modeled in CATIA V5R20 and analyses are carried out using ANSYS CFX. Triangle and square shapes are used as cavities for analysis. Simulations revealed that cavity placed on wing segment shows an increase of maximum lift co-efficient when compared to normal wing configuration. Flow separation is delayed at downstream of the wing by the presence of cavities up to a particular angle of attack.

Keywords: lift, drag reduce, square dimple, triangle dimple, enhancement of stall angle

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Authors: M. Heydari, A. Ghanami

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Heat pipe is simple heat transfer device which combines the conduction and phase change phenomena to control the heat transfer without any need for external power source. At hot surface of heat pipe, the liquid phase absorbs heat and changes to vapor phase. The vapor phase flows to condenser region and with the loss of heat changes to liquid phase. Due to gravitational force the liquid phase flows to evaporator section. In HVAC systems the working fluid is chosen based on the operating temperature. The heat pipe has significant capability to reduce the humidity in HVAC systems. Each HVAC system which uses heater, humidifier or dryer is a suitable nominate for the utilization of heat pipes. Generally heat pipes have three main sections: condenser, adiabatic region, and evaporator. Performance investigation and optimization of heat pipes operation in order to increase their efficiency is crucial. In the present article, a parametric study is performed to improve the heat pipe performance. Therefore, the heat capacity of heat pipe with respect to geometrical and confining parameters is investigated. For the better observation of heat pipe operation in HVAC systems, a CFD simulation in Eulerian- Eulerian multiphase approach is also performed. The results show that heat pipe heat transfer capacity is higher for water as working fluid with the operating temperature of 340 K. It is also showed that the vertical orientation of heat pipe enhances it’s heat transfer capacity.used in the abstract.

Keywords: heat pipe, HVAC system, grooved heat pipe, heat pipe limits

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Authors: Ravindra Raju, Vidhu Kampurath

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For smooth transition of the power from the engine to the transmission system, a clutch is used. In agricultural tractors, friction clutches are widely used in power transmission applications. To transmit the maximum torque in friction clutches, selection of materials is one of the important tasks. The present used material for friction disc is Asbestos, Ceramic etc. In this study, analysis is performed using composites materials. The composite materials are considered due to their high strength to weight ratio. Composite materials like kevlar49, kevlar 29U were used in the study. The paper presents a systematic approach to optimize the structural and thermal characteristics of the clutch friction pad. A single plate clutch is modeled using Creo 2.0 software and analyzed using ANSYS. Thermal analysis considers the reduction of heat generated between the friction surfaces and reducing the temperature rise during the steady state period. Structural analysis is done to minimize the stresses developed as a result of the loading contact between friction surfaces. Also, modal analysis is done to optimize the natural frequency of the friction plate to avoid being in resonance with the engine frequency range. The analysis carried out on ANSYS workbench to get the foremost appropriate friction material for clutch. From the analyzed results stress, strain / total deformation values and natural frequency of the materials were compared for all the composite materials and the best one was taken out. For the study purpose, specifications of the clutch are obtained from the MF1035 (47KW) Tractor model.

Keywords: ANSYS, clutch, composite materials, creo

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Authors: Ayoade Adeyemi, Leo Nherera, Paul Trueman, Antje Emmermann

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Background and objectives: Radiofrequency (RF) generated plasma chondroplasty is considered a promising treatment alternative to mechanical debridement (MD) with a shaver. The aim of the study was to perform a cost-effectiveness analysis comparing costs and outcomes following COBLATION chondroplasty versus mechanical debridement in patients with knee pain associated with a medial meniscus tear and idiopathic ICRS grade III focal lesion of the medial femoral condyle from a payer perspective. Methods: A decision-analytic model was developed comparing economic and clinical outcomes between the two treatment options in German patients following knee chondroplasty. Revision rates based on the frequency of repeat arthroscopy, osteotomy and conversion to total knee replacement, reimbursement costs and outcomes data over a 4-year time horizon were extracted from published literature. One-way sensitivity analyses were conducted to assess uncertainties around model parameters. Threshold analysis determined the revision rate at which model results change. All costs were reported in 2016 euros, future costs were discounted at a 3% annual rate. Results: Over a 4 year period, COBLATION chondroplasty resulted in an overall net saving cost of €461 due to a lower revision rate of 14% compared to 48% with MD. Threshold analysis showed that both options were associated with comparable costs if COBLATION revision rate was assumed to increase up to 23%. The initial procedure costs for COBLATION were higher compared to MD and outcome scores were significantly improved at 1 and 4 years post-operation versus MD. Conclusion: The analysis shows that COBLATION chondroplasty is a cost-effective option compared to mechanical debridement in the treatment of patients with a medial meniscus tear and idiopathic ICRS grade III defect of the medial femoral condyle.

Keywords: COBLATION, cost-effectiveness, knee chondroplasty, mechanical debridement

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Authors: Saimir Heta, Ilma Robo, Rialda Xhizdari, Kers Kapaj

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The stability of an ideal disinfectant should be constant regardless of the change in the atmospheric conditions of the environment where it is kept. If the conditions such as temperature or humidity change, it is understood that it will also be necessary to approach possible changes in the holding materials such as plastic or glass bottles with the aim of protecting, for example, the disinfectant from the excessive lighting of the environment, which can also be translated as an increase in the temperature of disinfectant as a fluid. Material and Methods: In this study, an attempt was made to find the most recent published data about the best possible combination of disinfectants indicated for use after dental procedures. This purpose of the study was realized by comparing the basic literature that is studied in the field of dentistry by students with the most published data in the literature of recent years about this topic. Each disinfectant is represented by a number called the disinfectant count, in which different factors can influence the increase or reduction of variables whose production remains a specific statistic for a specific disinfectant. Results: The changes in the atmospheric conditions where the disinfectant is deposited and stored in the environment are known to affect the stability of the disinfectant as a fluid; this fact is known and even cited in the leaflets accompanying the manufactured boxes of disinfectants. It is these cares, in the form of advice, which are based not only on the preservation of the disinfectant but also on the application in order to have the desired clinical result. Aldehydes have the highest constant among the types of disinfectants, followed by acids. The lowest value of the constant belongs to the class of glycols, the predecessors of which were the halogens, in which class there are some representatives with disinfection applications. The class of phenols and acids have almost the same intervals of constants. Conclusions: If the goal were to find the ideal disinfectant among the large variety of disinfectants produced, a good starting point would be to find something unchanging or a fixed, unchanging element on the basis of which the comparison can be made properties of different disinfectants. Precisely based on the results of this study, the role of the specific constant according to the specific disinfectant is highlighted. Finding an ideal disinfectant, like finding a medication or the ideal antibiotic, is an ongoing but unattainable goal.

Keywords: different disinfectants, ideal, specific constant, dental procedures

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Authors: Esam I. Jassim

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The main aim of this paper is to demonstrate the prediction of the model capability of predicting the nucleation process, the growth rate, and the deposition potential of second phase particles in gas flowlines. The primary objective of the research is to predict the risk hazards involved in the marine transportation of compressed natural gas. However, the proposed model can be equally used for other applications including production and transportation of natural gas in any high-pressure flow-line. The proposed model employs the following three main components to approach the problem: computational fluid dynamics (CFD) technique is used to configure the flow field; the nucleation model is developed and incorporated in the simulation to predict the incipient hydrate particles size and growth rate; and the deposition of the gas/particle flow is proposed using the concept of the particle deposition velocity. These components are integrated in a comprehended model to locate the hydrate deposition in natural gas flowlines. The present research is prepared to foresee the deposition location of solid particles that could occur in a real application in Compressed Natural Gas loading and offloading. A pipeline with 120 m length and different sizes carried a natural gas is taken in the study. The location of particle deposition formed as a result of restriction is determined based on the procedure mentioned earlier and the effect of water content and downstream pressure is studied. The critical flow speed that prevents such particle to accumulate in the certain pipe length is also addressed.

Keywords: hydrate deposition, compressed natural gas, marine transportation, oceanography

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Authors: Sanchita B. Sarma, M. P. Nath

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Adequate analgesia following caesarean section decreases morbidity, hastens ambulation, improves patient outcome and facilitates care of the newborn. Intrathecal magnesium, an NMDA antagonist, has been shown to prolong analgesia without significant side effects in healthy parturients. The aim of this study was to evaluate the onset and duration of sensory and motor block, hemodynamic effect, postoperative analgesia, and adverse effects of magnesium or fentanyl given intrathecally with hyperbaric 0.5% bupivacaine in patients with mild preeclampsia undergoing caesarean section. Sixty women with mild preeclampsia undergoing elective caesarean section were included in a prospective, double blind, controlled trial. Patients were randomly assigned to receive spinal anesthesia with 2 mL 0.5% hyperbaric bupivacaine with 12.5 µg fentanyl (group F) or 0.1 ml of 50% magnesium sulphate (50 mg) (group M) with 0.15ml preservative free distilled water. Onset, duration and recovery of sensory and motor block, time to maximum sensory block, duration of spinal anaesthesia and postoperative analgesic requirements were studied. Statistical comparison was carried out using the Chi-square or Fisher’s exact tests and Independent Student’s t-test where appropriate. The onset of both sensory and motor block was slower in the magnesium group. The duration of spinal anaesthesia (246 vs. 284) and motor block (186.3 vs. 210) were significantly longer in the magnesium group. Total analgesic top up requirement was less in group M. Hemodynamic parameters were similar in both the groups. Intrathecal magnesium caused minimal side effects. Since Fentanyl and other opioid congeners are not available throughout the country easily, magnesium with its easy availability and less side effect profile can be a cost effective alternative to fentanyl in managing pregnancy induced hypertension (PIH) patients given along with Bupivacaine intrathecally in caesarean section.

Keywords: analgesia, magnesium, pre eclampsia, spinal anaesthesia

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Authors: Adam M. Yates, Julie E. Byles

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Hypertension has been identified as a prominent co-morbidity of obesity. To improve clinical intervention of hypertension, it is critical to identify metrics that most accurately reflect risk for increased morbidity. Two of the most relevant and accurate measures for increased risk of hypertension due to excess adipose tissue are Body Mass Index (BMI) and Waist-Height Ratio (WHtR). Previous research has examined these measures in cross-national and cross-ethnic studies, but has most often relied on secondary means such as meta-analysis to identify and evaluate the efficacy of individual body mass measures. In this study, we instead use cross-sectional analysis to assess the cross-ethnic discriminative power of BMI and WHtR to predict risk of hypertension. Using the WHO SAGE survey, which collected anthropometric and biometric data from respondents in six middle-income countries (China, Ghana, India, Mexico, Russia, South Africa), we implement logistic regression to examine the discriminative power of measured BMI and WHtR with a known population of hypertensive and non-hypertensive respondents. We control for gender and age to identify whether optimum cut-off points that are adequately sensitive as tests for risk of hypertension may be different between groups. We report results for OR, RR, and ROC curves for each of the six SAGE countries. As seen in existing literature, results demonstrate that both WHtR and BMI are significant predictors of hypertension (p < .01). For these six countries, we find that cut-off points for WHtR may be dependent upon gender, age and ethnicity. While an optimum omnibus cut-point for WHtR may be 0.55, results also suggest that the gender and age relationship with WHtR may warrant the development of individual cut-offs to optimize health outcomes. Trends through multiple countries show that the optimum cut-point for WHtR increases with age while the area under the curve (AUROC) decreases for both men and women. Comparison between BMI and WHtR indicate that BMI may remain more robust than WHtR. Implications for public health policy are discussed.

Keywords: hypertension, obesity, Waist-Height ratio, SAGE

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Authors: Arum Kingsley Chinedu, Ugwuowo Fidelis Ifeanyi, Oranye Henrietta Ebele

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The Poisson regression model (PRM) is a nonlinear model that belongs to the exponential family of distribution. PRM is suitable for studying count variables using appropriate covariates and sometimes experiences the problem of multicollinearity in the explanatory variables and outliers on the response variable. This study aims to address the problem of multicollinearity and outliers jointly in a Poisson regression model. We developed an estimator called the robust modified jackknife PCKL parameter estimator by combining the principal component estimator, modified jackknife KL and transformed M-estimator estimator to address both problems in a PRM. The superiority conditions for this estimator were established, and the properties of the estimator were also derived. The estimator inherits the characteristics of the combined estimators, thereby making it efficient in addressing both problems. And will also be of immediate interest to the research community and advance this study in terms of novelty compared to other studies undertaken in this area. The performance of the estimator (robust modified jackknife PCKL) with other existing estimators was compared using mean squared error (MSE) as a performance evaluation criterion through a Monte Carlo simulation study and the use of real-life data. The results of the analytical study show that the estimator outperformed other existing estimators compared with by having the smallest MSE across all sample sizes, different levels of correlation, percentages of outliers and different numbers of explanatory variables.

Keywords: jackknife modified KL, outliers, multicollinearity, principal component, transformed M-estimator.

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Authors: Karolina Siejka, Monika Piekarska, Monika Zbroja, Weronika Cyranka, Maryla Kuczynska, Magdalena Grzegorczyk, Malgorzata Nowakowska, Agnieszka Brodzisz, Magdalena Maria Wozniak

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Crohn’s disease is one of chronic inflammatory bowel diseases. It is increasing in prevalence worldwide, especially with young people. The disease usually occurs in the second to the fourth decade of life. Traditionally is diagnosed by clinical indicates, endoscopic, and histological findings. Magnetic Resonance Enterography (MRE) can demonstrate mural and extramural inflammatory signs and complications, which make it a valuable diagnostic modality. The study included 76 adults and 36 children diagnosed with Crohn’s disease. Each patient underwent MRE with intravenous administration of a contrast agent. All the studies were performed using Siemens Aera 1.5T scanner according to a local study protocol. Whenever applicable, MR Enterography findings were verified with endoscopy. Forty adults and all 36 children had an active phase of Crohn’s disease; five adults had a chronic phase of the disease; one adult had both chronic and active inflammatory features. Thirty adults have no sings of pathology. In both adult and pediatric groups the most commonly observed manifestation of active disease was thickened edematous ileum wall (26 adults and 36 children). Adults had Bauhin’s valve edema in 58% cases (n=23) and mesenteric changes in 34% cases (n=9). To compare, 32 children had Bauhin’s valve edema (89%) and, in 23 cases, was found inflammatory infiltration of the peri-intestinal fat (64%). The involvement of the large intestine was more common among children (100%). Complications of Crohn’s disease were found commonly in adults (40% of adults, 22% of children). There were observed 18 fistulas (14 adults, four children) and six abscesses (2 adults, four children). MRE is a reliable method in the evaluation of Crohn’s disease activity, especially of its complications. The lack of radiations makes MRE well-tolerated modality, which can be often repeated, particularly in young patients. The disease had different medical sings depending on age – children often had a more active inflammatory process, but there were more complications in the adult group.

Keywords: Crohn's disease, diagnostics, inflammatory bowel disease, magnetic resonance enterography, MRE

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Authors: Melba Sheila D'Souza, Anandhi Amirtharaj, Shreedevi Balachandran

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Background: Type 2 diabetes has a significant impact on individuals’ health and well-being. Glycemic control may influence self-efficacy and self-care behaviors, and reduce the risk of complications among adults with type 2 diabetes. Type 2 diabetes has substantial morbidity and mortality and 60% of adults’ poor self-care. Glycemic control is associated with reported self-efficacy and self-care behavior. Adults with type 2 diabetes with less information were less likely to take diabetes self-care. Aim: To examine the relationship between glycemic control, demographic factors, clinical factors on self-efficacy, self-care behaviors among Omani adults with type 2 diabetes. Methods: A correlational, descriptive study was used. Omani adults with type 2 diabetes (n=140) were recruited from a public hospital in Oman. The data were collected during January-March 2015. Ethical approval was given by the college research and ethics committee, College of Nursing, and the Hospital, Sultan Qaboos University Data was collected on self-efficacy, self-care behaviors and glycemic control. The study was approved by the Institution Ethics and Research Committee. Bivariate and multivariate analyses were conducted. Results: Most adults had a fasting blood glucose >7.2mmol/L (90.7%), with the majority demonstrating ‘uncontrolled or poor HbA1c of > 8%’ (65%). Variance of self-care behavior (20.6%) and 31.3% of the variance of the self-efficacy was explained by the age, duration of diabetes, medication, HbA1c and prevention of activities of living. Adults with type 2 diabetes with poor glycemic control were more likely to have poor self-efficacy and poor self-care behaviors. Conclusion: This study confirms that self-efficacy model on outcome predicts self-efficacy and self-care behavior. Higher understanding of diabetes, prevention of normal daily activities, higher ability to fit diabetes life in a positive manner and high patient-physician communication were significant with self-efficacy and self-care behaviors. Hence, glycemic control has a high effect on improving self-care behaviors like diet, exercise, medication, foot care and self-efficacy among type 2 diabetes. Implications: Using these findings to improve self-efficacy, individualized self-care management is recommended for better self-efficacy and self-care behaviors among adults with type 2 diabetes.

Keywords: self-efficacy, self-care behaviors, self-care management, glycemic control, type 2 diabetes, nurse

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